National Trends in the Office-Based Treatment of Children, Adolescents, and Adults With Antipsychotics
Context Although antipsychotic treatment has recently increased, little is known about how this development has differentially affected the office-based care of adults and young people in the United States.
Objective To compare national trends and patterns in antipsychotic treatment of adults and youths in office-based medical practice.
Design Trends between 1993 and 2009 in visits with antipsychotics for children (0-13 years), adolescents (14-20 years), and adults (≥21 years) are described on a per population basis and as a proportion of total medical office visits. Background and clinical characteristics of recent (2005-2009) antipsychotic visits are also compared by patient age.
Setting Outpatient visits to physicians in office-based practice.
Participants Visits from the 1993-2009 National Ambulatory Medical Care Surveys (N = 484 889).
Main Outcome Measures Visits with a prescription of antipsychotic medications.
Results Between 1993-1998 and 2005-2009, visits with a prescription of antipsychotic medications per 100 persons increased from 0.24 to 1.83 for children, 0.78 to 3.76 for adolescents, and 3.25 to 6.18 for adults. The proportion of total visits that included a prescription of antipsychotics increased during this period from 0.16% to 1.07% for youths and from 0.88% to 1.73% for adults. From 2005 to 2009, disruptive behavior disorders were the most common diagnoses in child and adolescent antipsychotic visits, accounting for 63.0% and 33.7%, respectively, while depression (21.2%) and bipolar disorder (20.2%) were the 2 most common diagnoses in adult antipsychotic visits. Psychiatrists provided a larger proportion of the antipsychotic visits for children (67.7%) and adolescents (71.6%) than to adults (50.3%) (P < .001). From 2005 to 2009, antipsychotics were included in 28.8% of adult visits and 31.1% of youth visits to psychiatrists.
Conclusions On a population basis, adults make considerably more medical visits with a prescription of antipsychotics than do adolescents or children. Yet antipsychotic treatment has increased especially rapidly among young people, and recently antipsychotics have been prescribed in approximately the same proportion of youth and adult visits to psychiatrists.
Over the past several years, an increasing number of adults and children in the United States have been treated with antipsychotic medications.1 – 2 Antipsychotics are now among the most commonly prescribed and costly classes of medications.3 In adults, antipsychotic medications have demonstrated efficacy and have been approved by the Food and Drug Administration (FDA) as a primary treatment for schizophrenia4 – 5 and bipolar disorder6 – 7 and as an adjunctive treatment for major depressive disorder.8 In children and adolescents, antipsychotics are indicated for irritability associated with autistic disorder (5-16 years), tics and vocal utterances of Tourette syndrome and bipolar mania (10-17 years), and schizophrenia (13-17 years).9
With increasing use of antipsychotic drugs, the range of mental disorders treated with these medications in practice has broadened.10 – 15 As a result, the proportion of second-generation antipsychotic medications prescribed to treat schizophrenia has decreased from 51% (1995-1996) to 24% (2007-2008),2 while antipsychotic treatment of anxiety disorders in adults and youths has roughly doubled.12 In young people, attention-deficit/hyperactivity disorder and other disruptive disorders account for a substantial proportion (37.8%) of antipsychotic use.11
The metabolic safety concerns of antipsychotic medications16 – 17 focus our attention on antipsychotic prescribing practices in the community, especially on the extent to which antipsychotics are used to treat disorders for which there is limited empirical evidence of efficacy.15 ,18 Young people may be especially sensitive to the adverse metabolic effects of second-generation antipsychotics. As compared with adults, children may be more vulnerable to antipsychotic-induced weight gain19 and perhaps even to antipsychotic-associated diabetes.20 – 21
Young people and adults vary in several important clinical respects22 that might influence trends in antipsychotic use. Disruptive behavioral disorders, which are more commonly diagnosed in boys than in girls23 and in nonwhite youths than in white youths,24 – 25 occur in a substantial proportion of young people receiving outpatient mental health care.26 Increasing clinical acceptance of antipsychotics for problematic aggression in disruptive behavior disorders27 may have increased the number of children and adolescents (especially male youths and ethnic/racial minorities) being prescribed antipsychotics. The increase in the number of clinical diagnoses of bipolar disorder28 and autistic spectrum disorders29 among children and adolescents may have further increased antipsychotic use by youths, particularly by boys. With respect to adults, acceptance of antipsychotics as adjuvant treatment of major depressive disorder, even in the absence of psychotic features,30 might have increased antipsychotic use. Because depressive disorders are significantly more common in women than in men,31 such a trend might preferentially increase antipsychotic use among adult women. Increasing use of antipsychotics in adult anxiety disorders may have a similar effect.12
A comparison is presented of nationally representative survey data from adult and youth visits to office-based physicians. The analyses focus on trends and patterns of antipsychotic treatment. Prior to conducting these analyses, we predicted that the increase in the proportion of physician visits with a prescription of antipsychotic medications would be more pronounced for youths than for adults.